DISTAL ARTERIOVENOUS-FISTULA AS AN ADJUNCT TO MAINTAINING ARTERIAL AND GRAFT PATENCY FOR LIMB SALVAGE

  • 1 January 1983
    • journal article
    • research article
    • Vol. 94  (3) , 478-486
Abstract
Distal arteriovenous fistulas (dAVF) (61) were constructed as adjuncts to tibial and peroneal vascular reconstructive procedures in 58 patients threatened with imminent limb loss. Specific indications for dAVF construction were absent or deficient pedal arches, usually associated with small, calcareous crural vessels. Conventional bypasses were previously performed in 35 patients. Cumulative graft patency rates were 56, 39 and 18% at 6, 12 and 24 mo., respectively. For the same intervals, the figures were 56, 52 and 52% (P < 0.001 at 24 mo.) for nonAVF 52% and 40% for the dAVF group and 78%, 72% and 72% for the non-AVF group (P < 0.05 at 24 mo.) for nonAVF reconstructions (n = 49). The corresponding cumulative limb salvage rates were 62, 52 and 40% for the dAVF group and 78, 72 and 72% for the nonAVF group (P < 0.05 at 24 mo.). The perioperative mortality rate was 7% (4 of 61). Twenty-four amputations were required, of which 16 were below the knee and 6 despite patent grafts. There was no significant morbidity attributable directly to the dAVF. Cardiac output showed no deviations from normal values. Primary causes of early failure were infection (n = 4), absence of satisfactory veins (n = 6) and inappropriate case selection (n = 7). Intimal hyperplasia led to dAVF closure and graft failure in 13 patients. dAVF apparently can maintain graft patency by diversion of the overload on a high-resistance vascular bed and, secondarily, by augmentation of inflow. Immediate survival of the limb still depends on the arterial runoff, as retrograde venous flow caused by venous valvular incompetence is a delayed development. Adjunctive dAVF is justified in selected cases where conventional bypass failure has occurred or is predictable by increased pedal vascular resistance.